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We asked a gender nonconforming therapist how healthcare providers can become trans-competent and avoid unintentionally harming patients.

Whether in an emergency room, a therapy session, or sitting through a routine checkup, trans people are often subject to blatant transphobia in health and mental healthcare settings. More insidious, however, are the myriad ways trans people experience microaggressions. Though trans microaggressions — defined as indirect, subtle, or unintentional instances of discrimination against members of a marginalized group (in this case, transgender people) — are not typically motivated by malice, they can still have a significant negative impact on a patient’s experience, contribute to lower standards of care, and can serve as a deterrent the next time a trans patient needs care.

One third of trans patients have had at least one negative healthcare experience in the past year related to being transgender. Even more troubling, 23 percent of trans patients report avoiding needed medical attention altogether for fear of being mistreated.

To address this issue, we asked Jesse Kahn — a gender nonconforming clinical social worker, psychotherapist, and consultant who specializes in working with transgender and gender nonconforming individuals — to explain some of the most common trans microaggressions trans people face in health and mental healthcare settings.

1. Asking for a “real” name or “preferred” pronouns

The name a trans person goes by is their “real” name. If a provider needs to know the patient’s legal name, then they should explicitly ask if the patient has a different legal name. Seemingly small word choices can have a major impact on the message a provider is sending, so it’s important to be intentional. Similarly, providers shouldn’t ask for “preferred” pronouns — they should just ask for a person’s pronouns. Period. Adding the word “preferred” is minimizing, and suggests it’s an arbitrary choice. Additionally, it’s important to know how and when to use gender neutral pronouns such as “they/them/their.”

2. Using words like “regular” or “normal” as synonymous for heterosexual or cisgender

When a provider uses the words “regular” or “normal” to mean cisgender, the implication is that cisgender people are superior and that trans people are inferior and abnormal. There should be no baseline for gender identity or sexual orientation that providers use to compare their patients against. Every patient is unique. Evaluate them within the context of their own experience.

Trans patients are entitled to the same privacy as any other patient. Asking intrusive questions – especially ones you wouldn’t ask cisgender patients — is invasive and sensationalizing. This includes asking questions about gender identity, sexual activity, or surgeries if those questions have nothing to do with a patient’s care. It is important to be constantly mindful of why certain questions are asked.

4. Focusing on gender and sexuality when that’s not an issue in treatment

Similarly, if a trans patient is coming in for a flu shot, the conversation should not suddenly shift to body modifications or genitalia. Providers should focus on the health issue at hand, and not overstep in a way they wouldn’t consider appropriate with cisgender patients. Similarly in mental health care, a patient’s presenting problem may not be related to gender identity. Trans patients will be looking for a therapist who will not inappropriately focus on or pathologize their identity.

Gender is not a binary where the choices are only “man” and “woman.” Providers shouldn’t force their patients into this binary, and may do so without realizing it. All people have different goals for their transition. Rather than relying on assumptions based off societal norms or the choices of other trans patients, providers should allow the patient to explain their goals. This can be as simple as asking “do you have transition related goals? And if so, what are they?” It’s important to remember that goals for transition may have nothing to do with medical interventions.

6. Expressing assumptions about trans narratives

Every trans person’s history, journey to self-realization, and sense of self is unique. Providers should allow patients to present their own stories, rather than relying on a trans narrative with which the provider is already comfortable or familiar. For example, instead of asking a trans patient whether they’ve “always known” if they were trans, asking open ended questions about their journey to self-realization, when they first acknowledged gender identity, first verbalized feelings around gender, or when they first developed a desire to transition. Assuming a “born in the wrong body” narrative often upholds binary thinking, assumes how a trans person may feel about their body, and does not allow for fluidity in gender identity and expression.

7. Assuming who someone dates

Gender and sexuality are separate, so providers should never assume what gender(s) a person is attracted to. Rather than asking about a “boyfriend” or “girlfriend,” providers should use gender-neutral words like “partner(s).”

Finding Competent Care

Even the most well-intentioned and educated providers can find themselves guilty of these trans microaggressions. Conscious, competent care is a matter of actively unlearning ingrained cis- and heteronormative ideals that manifest in the language we use. Providers should regularly check-in with themselves and their colleagues to ensure they’re listening to — and affirming — their transgender patients. Additionally, providers and organizations should prioritize seeking formal education, training, consultation, and supervision with organizations such as The Gender and Sexuality Therapy Collective.

At Lighthouse, our goal is to connect LGBTQ patients with informed providers — because no one should be made to feel misunderstood or alienated when it comes to something as essential as their medical and mental health.